HomeMy WebLinkAbout2026-00059017 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IM UHI U� I� 1lUll I11l11111111UU
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X091:51
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ElOVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2026I 2026-00059017 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 mMARTIN DR Elgin
® ❑ RELATED 0 Y ®N 09 28 2026 ❑AM ❑YES IX]PRIVATENO U1
mo /day/yr 03:06 ®PM FLOW CONDITION m
®!MI N OE S W HIAWATHA Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
R80P,r TOWED U1 Q
NAME(LAST,FIRST,M) mo yr
Gonzalez.Jan.C. Dodge Caravan(inc Grand)2014 00-NONE 11
i DUE TOCRASH ❑ EN
Q -
13-UNDER CARRIAGE i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ gi U2 2
16 m
M 2 SYTM IN ENGAGE4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TIDP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 I,.4 COM VEH 0 LK 1 0
I .
ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; _5 *Yves.See Sidebar U1
Z V380300 IL 2027 REAR
TELEPHONE
IL D 0 2C4RDGCG2ER170077 Geico ❑Y ®N U2 I—
i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Gonzalez Sanchez. Leslie 6204124991 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
0 DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 10 j 12 c, 2 FIRE ❑ ❑ U2 C
0 13-UNDER CARRIAGE
c
M 1 3 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value
:A
l N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT OO 8 7A-j"-4 COM VEH 0 El
=5 •If U1 COes.See Sidebar CZ Chicago IL 60651 B 1 0)
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IL D 0 ❑y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 48 2 Gonzalez Sanchez. Leslie BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),{ADDRESS)((TELEPHONE) {EMS) (HOSPITAL)
0
E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 09,28 ,2026 03 06 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 23 09,28 ,2026 03 07 ®PM 0 Construction
>F
R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ❑AM 0 Maintenance U2
o ® 12 4 ARREST NAME Gonzalez.Jan.C. 11-601 1530000890 09,28 i2026 03 13 Igi pM• • El SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 0 ARREST NAME Gonzalez.Jan.C. 11-1204-B 1530000891 09,28 ,2026 03 26 ®pM El Unknown work zone type U1 25
2 2 3 ID ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1530-Soto.Oscar 201 11 ,03,2026 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
\ _ } (example:shuttle or charter bus):or
X
\ 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
'� } } } transporting employee In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or �
C
-- -- 0 Untt? I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)for direct compensation(example:large van used for specific purpose):or 0
Martin?Dr t i. } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
Not To Scale 1 placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0II C
C)
Hiawatha?Dr I CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
Xi
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xi
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE